Kids Still Use Snuff, 'Chaw'

Action Points

No significant change in overall smokeless tobacco prevalence occurred in a national cross-sectional survey of U.S. middle and high school students between 2000 and 2011.

However, the prevalence of self-reported use of snuff, chew, or dipping tobacco increased in those ages 15 to 17.

More than a decade into the new century, teens and adolescents were as apt to use chewing tobacco and snuff as they were at its start, a national survey showed.

The overall prevalence of smokeless tobacco use came in at 5.3% in 2000 and 5.2% in 2011 among middle and high school kids, Israel Agaku, DMD, MPH, of Harvard School of Public Health and the University of Pretoria in South Africa, and colleagues found.

These findings from the school-based National Youth Tobacco Survey appeared in a research letter in the May 15 issue of the Journal of the American Medical Association.

Smokeless tobacco use had also been on the decline through the late '80s and '90s, according to another study, which Agaku's group noted was "before the increased availability of flavored products that may appeal to youths."

The government's tough approach to cigarettes by raising taxes, requiring stronger warning labels, and banning flavors didn't carry over to smokeless tobacco, noted co-author Gregory Connolly, DMD, MPH, director of the Center for Global Tobacco Control at the Harvard School of Public Health.

Even distribution of free samples isn't prohibited for smokeless tobacco, his group pointed out.

"We have to treat all tobacco products alike," Connolly said in an interview. "Otherwise we see this switching of youngsters away from cigarette smoking to combined use of smokeless tobacco and cigarettes and that is not going to reduce the disease risk in our nation from tobacco."

The message for the clinic and for policy is not to overlook smokeless tobacco use, he argued.

"If all we're seeing is a switch in cancer from the lung to the mouth, we may not have made the clinical progress we hoped to see with our campaign against tobacco," he added. "Keep in mind that 50% of persons diagnosed with oral cancer are dead in 5 years. It's a very aggressive cancer, it will spread quickly from the oral cavity to other parts of the body."

In the biennial survey of middle and high school students ranging from 35,828 in 324 schools in 2000 to 18,866 in 178 schools in 2011, the trends differed by age.

Self-reported use of snuff, chew, or dipping tobacco at least once over the prior month fell by 4.6% per year in kids, ages 9 to 11, and 3.4% per year in those 12 to 14 (P=0.007 and P=0.02 for linear trend).

But that prevalence rose by 0.9% per year among 15- to 17-year-olds (P=0.01 for linear trend).

The reason may be that those 14 and under are more affected by the implementation of federal legislation enforcing age verification when purchasing tobacco and by many states' bans and restrictions on mail order and Internet tobacco sales, the researchers suggested.

"Furthermore, the promotion of smokeless tobacco use as an alternative to smoking is more likely directed at smokers, who are more likely to be older than younger adolescents," the group added.

Race, ethnicity, and sex weren't significant factors.

Limitations included the lack of data on type of smokeless tobacco used or newer smokeless tobacco products, such as snus (moist snuff) and dissolvable tobacco, and by potential recall bias.

"Nonetheless, these findings emphasize the need for evidence-based interventions to reduce smokeless tobacco use among youths," the group concluded.

The study was funded by National Cancer Institute grants.

One co-author reported serving on speakers' bureaus for Pfizer.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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